gastro esophageal reflux disease (gerd)...pathogenesis signs &symptoms ... cough, and laryngitis...

D R . A M M A R I . A B D U L - L A T I F

Gastro esophageal reflux disease(GERD)

GERD

DEFINITION

EPIDEMIOLOGY

CAUSES

PATHOGENESIS

SIGNS &SYMPTOMS

COMPLICATIONS

DIAGNOSIS

TREATMENT

Definition

Montreal consensus defined GERD as

“a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.”

The term “troublesome” has been defined as negatively affecting an individual’s sense of well-being

EPIDEMIOLOGY

• GERD is a common condition with prevalence rates as high as 40% in North America and

Western Europe, and somewhat lower rates in South America and Asia.

• More than 50% of patients with symptomatic reflux symptoms have no esophageal injury.

NORMAL ANATOMY &PHYSIOLOGY

Etiology and pathogenesis

A high pressure zone located between the intra-abdominal stomach and the intrathoracic esophagus is responsible for preventing the retrograde flow of stomach contents into the esophagus. This high pressure zone is created by contributions from the lower esophageal sphincter (LES) and the crural diaphragm. The LES is a 4-cm segment of circular muscle in the distal esophagus that is tonically closed because of the intrinsic myogenic properties of this specialized segment. The crural diaphragm augments the LES during times of increased demand, such as straining or coughing, which increase intra-abdominal pressure. A defective LES with reduced basal pressure is one mechanism for the development of GERD

Etiology and pathogenesis

• Prolonged transient lower esophageal sphincter relaxation (TLESR) represents the major mechanism by which GERD occurs.

• Gastro esophageal reflux also requires a positive pressure gradient between stomach and the high pressure zone. Straining and obesity are examples of conditions that increase abdominal pressure and contribute to a risk of GERD.

Etiology and pathogenesis

• Displacement of the cardio esophageal junction above the crural diaphragm, which generally occurs as a result of the presence of a hiatus hernia, contributes to GERD by:

• Loss of the diaphragmatic contribution to the high-pressure zone.

• Increasing the pressure gradient between stomach and distal esophagus.

• Migration of an acid pocket above the diaphragm with increased acid exposure in the distal esophagus.

Factors Associated With GERD

Clinical Picture-Signs &Symptoms

Esophageal:

Heart burn

Regurgitation

Pain(epigastric,chest)

Extraesophageal:

:a. Established

Chronic cough.

Chronic laryngitis.

Asthma.

Dental erosions

Clinical Picture-Signs &Symptoms

b. Proposed :

• Pharyngitis.

• Sinusitis.

• Idiopathic pulmonary fibrosis.

• Recurrent otitis media.

Clinical Picture-Complications

Erosive esophagitis.

Esophageal stricture.

Barrett’s esophagus .

Esophageal adenocarcinoma

Chronic occult bleeding as well as overt hemorrhage also may result from esophageal ulceration

Diagnosis

Clinical picture: (Differential Dx :infectious esophagitis,pill-induced esophagitis, eosinophilic esophagitis, PUD, NUD)

Upper endoscopy should be considered in

Patients with suspected GERD who have::either-

-An alarm symptoms (dysphagia, significant weight loss, anemia, or signs of GI bleeding)

- Patients fail to respond to empirical proton pump inhibitor (PPI) therapy

Diagnosis-Upper endoscopy

Diagnosis-Upper endoscopy

EOSINOPHILIC ESOPHAGITIS

ESOPHAGEAL CANDIDIASIS

Differential diagnosis-Upper endoscopy

HSV-ESOPHAGITIS CMV-ESOPHAGITIS

Differential diagnosis-Upper endoscopy

BARRETT PEPTIC STRICTUR

COMPLICATIONS OF GERD-UPPER ENDOSCOPY

Differential diagnosis-ExtraesophagealManifestations

GERD has been associated with asthma, chronic cough, and laryngitis . It is important to eliminate other non GERD causes when these symptoms are present. Laryngoscopy often demonstrates edema and erythema as signs of reflux induced laryngitis; however, over 80% of healthy persons also have these findings. Laryngoscopy should not be used to diag nose GERD-related laryngitis. A PPI trial is recommended in patients who have typical GERD symptoms and extraesopha geal symptoms

Diagnosis

• Esophageal manometry is useful for evaluating patients with either dysphagia or atypical chest pain who fail to respond to PPI therapy.and it is indicated before anti-reflux surgery.

• Ambulatory impedance-pH monitoring usingcatheter, or wireless capsule may be helpful in the

evaluation of patients who have not responded to twice daily dosing of a PPI.

Treatment

Life style modification

Medical Treatment

Surgical Treatment

Endoscopic Treatment

Treatment-Life style modification

Weight reduction is suggested for patients with recent weight gain or for those who are overweight

Raising the head of the bed and eliminating meals within 2 to 3 hours of bedtime are helpful for nocturnal GERD .

Targeted elimination of foods associated with symptoms( global elimination of proposed trigger foods (caffeine, chocolate, spicy foods, acidic foods such as oranges, and fatty foods) is not recommended ).

Cessation of alcohol and tobacco use is universally supported

Treatment-Medical

Step-Up &Step-D0wn ApproachAntacids

H2 blockers

PPI therapy

=PPI therapy once daily for 8 weeks is the therapy of choice for symptom relief.

=PP! therapy is superior to H2 blockers for treatment of GERD.

=It has been shown to offer faster healing rates for erosive esophagitis and decreased relapse compared with other agents.

= It also has been shown to offer faster and more complete relief of symptoms

Treatment-Medical

.-A PPI should be taken once daily 30 to 60 minutes before the first meal of the day.

-Patients with a partial response to PPI therapy should have their dose increased to twice daily.

- Patients who require long-term maintenance therapy should receive the lowest effective PPI dose, including on-demand or intermittent usage.

-Despite earlier concerns that concurrent PPI therapy decreased the activation of clopidogrel, two randomized clinical studies have since failed to show an increased risk of adverse outcomes in patients treated with clopidogrel and PP!s.

-PP!s are safe in pregnant patients.

Treatment-Medical

Common adverse reactions to PPIs are headache and diarrhea; dyspepsia may occur with sudden discontinuation of PP! therapy.

Switching to a different PP! may be helpful if the patient has an adverse reaction or if there is no clinical response; however, outcomes may remain the same with a different PP!.

Treatment-Medical

Other possible adverse reactions include vitamin (D) and mineral (calcium and magnesium)

malabsorption as well as increased risk of community-acquired pneumonia,

Clostridium difficile infection, hip fractures, osteoporosis, and cardiovascular events.

Hip fracture risk may not be increased unless other risk factors are present. Short-term PP! use has been linked to community-acquired pneumonia, but longterm use has not been similarly associated.

Refractory Gastroesophageal Reflux Disease

The first step in treating refractory GERO is to: -=Optimize PPI therapy by verifying correct administration (30-60 minutes before meals), Increasing to twice-daily dosing, or switching to another PP!.

=If symptoms remain unresponsive, alternative causes should be considered.

= In patients with typical symptoms, upper endoscopy should be performed to rule out eosinophilic esophagitis or erosive esophagitis. If the endoscopy does not reveal eosinophilic esophagitis or reflux-related changes, pH-impedance testing should be performed

Refractory Gastroesophageal Reflux Disease

. A negative pH-impedance test likely indicates that PP! therapy should be discontinued and that the patient does not have GERD.

-For those with prominent extra esophageal manifestations, referral to an otolaryngologist, pulmonologist, or allergist should be considered.

Treatment

Antiref1ux Surgery

Surgical treatments for GERD consist of' laparoscopic f'undoplication or bariatric surgery (the latter for obese patients).

Indications for surgery include -Patient preference to stop taking medication.

-Medication side effects.- Large hiatal hernia.

- Refractory symptoms despite maximal medical therapy (although patients with medically refractory symptoms may be less likely to benefit from surgery).

Patients should undergo objective testing (such as pH-impedance monitoring to demonstrate true reflux with symptom correlation and manometry to rule out a motility disorder) prior to surgery

Antiref1ux Surgery

Surgery is most effective in patients with typical symptoms or heartburn and regurgitation that are responsive to therapy.

However. approximately one third of patients will require resumption of' PP! therapy 5 to 10 years after surgery.

Postoperative complications include dysphagia, diarrhea. and inability lo belch because of a tight fundoplication. Carbonated beverages should be avoided

Transoral( incision less )fundoplication is a newer therapy that uses a full-thick ness suture to create an endoscopic fundoplication; however, there are no long-term data that demonstrate efficacy.

.

Antiref1ux Surgery

Endoscopic Therapy

Endoscopic therapies for GERD have not been shown to be effective in the long term. Therapies have included thermal radiofrequency to augment the LES, silicone injection to the LES, and suturing of the LES.

Early improvement of reflux symptoms has been seen, but long-term benefits have not been shown. Normalized esophageal pH levels have not been demonstrated after endoscopic therapies.

Endoscopic Therapy

TREATMENT ALGORYTH

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